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i APPLICATION <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PRONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> } (Complete in Triplicate) <br /> e to San"Joaquin County for a permit to construct and/or install the Work herein described. This I <br /> Application is hereby orad i <br /> application 1a made in complianceffwith San Joaquin County Ordinance No. 5�9 and 1862 and the Rules <br /> and Regulations of an <br /> Josquin County Public Health Servi6es. <br /> y y;R1i City Lot size/Acreage <br /> Job Address <br /> � N Y Address <br /> Il Phone <br /> 37, co J�"s7 <br /> Owner's Name {{ <br /> I� I1. 34 INP�,{'L License No. 2�t?i3 f hone <br /> Contractor D�r3N f` Address _.�..� Well 0 <br /> NEW WELL ❑ WELL REPLACEMENT C1 M0 <br /> ❑ Out oMO f Service Well C]TYPE OF WELL/PUMP! SYSTEM REPAIR 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL 0 LL PITS/SUMPS <br /> FOUNDATION -- <br /> INTENDED USE TYPE OF WELL PROBLJ EM AREA CONS ON SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom 0 Manteca ia. of Well Excavation <br /> n Industrial Specifications„ <br /> Type of Casing_ <br /> n Domestic/Private ❑ Gravel Pack Y Type <br /> I'I Public of Grout <br /> f-1 Other It (l Delta Depth of Grout Seal <br /> I } IrriOatian prax. Depth l I Eastern 5uriace Seal Installed by <br /> Repair Work Done mp <br /> Type of Pu -- <br /> - H P �- --_ State Work Done— <br /> + Sealing Material dr Depth <br /> Well De ion ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INS' ILLATION I 1 REPAIflIADDITIt3N { I DESTRUCT N a it bletiwithine200 lostrmi.) it public sewer is <br /> Installation will serve: Residence Commercial Other ,. <br /> Number of living units: 4 Number of bedrooms F <br /> Water,table depth <br /> Character of &oil to a depth of 3 feet`I �Y No. Compartments <br /> SEPTIC TANK Type/Mfg, g" t�0 V.b Capacity 2SfJ <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ � Property Line 2S 1 <br /> Distanceto nearest: Well Foundation <br /> ' TVMI length/size <br /> LEACHIN E ❑ No. & Length of lines �.� <br /> Pro ert Line <br /> FILT BfD ❑ Distanced to nearest: Well Foundation P Y <br /> �I <br /> Site Number <br /> j SEEPAGE P ( I Depth Property Line <br /> SUMP LI Distance to nearest: Well Foundation <br /> D OSALPONDS ❑ <br /> I _ � <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> ity signature certifies the following: "I cart that in the performance of the work for which this permit is issued, l not <br /> Home owner or licensed agent's to become subject to workman's compensation laws of California." Contractor's hiring sub contracting signature ture <br /> employ any person in such manner as <br /> canities the following: "I certify that in th a performance of the work for which this permit is issued, I shat!employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must caN or ell required inspections. Complete drawing on reverse side. <br /> Title: SF-Vt ` '2-+ � Date: *30 <br /> ( Signed <br /> f R DEPARTMENT USE ONLY <br /> Date _ j: Area <br /> Application Accepted by �Q <br /> is <br /> Pit or Grout Inspection by Data -- Final inspection by <br /> Date � � <br /> i Additional Comments: <br /> 4,/4 <br /> rcwtc .����ress e/l Al w �� <br /> k Applicant - Return all copies to: San Joaquin County Public Health Services <br /> + Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> ACK RECEIVED By DATE PERMIT'Np. <br /> lNFO AMOUNT D111; MOUNT REMITTED CASH <br /> � f�J <br /> . EM 13 24{RtY, <br /> i fl <br /> r EN i4•7a <br />